Laterally hypertrophic adenoids as a contributing factor in otitis media

A Prospective Comparative Study of Impedance Audiometry Findings Preoperatively and Postoperatively in Cases of Conventional Adenoidectomy versus Microdebrider Assisted Adenoidectomy

The aim of the study was to evaluate and compare the efficacy of Endoscopic Adenoidectomy with Microdebrider over Conventional technique by Curettage using Impedance Audiometry findings. In this prospective, randomised, comparative study patients were divided into two groups to undergo one of the above adenoidectomy surgeries. Patients with symptoms of Adenoid hypertrophy after failed maximal medical therapy (12 weeks) were selected after due consideration of the inclusion and exclusion criteria. Baseline Impedance Audiometric assessment was done one week prior to surgery which was compared to Impedance Audiometric values 12 weeks post operatively in each group. This study enrolled 50 patients with adenoid hypertrophy, 25 patients of group A underwent Conventional adenoidectomy and the other 25 patients of group B underwent Endoscopic Adenoidectomy with Microdebrider. Significant difference in type of tympanogram before and after adenoidectomy was found in both the groups (p = 0.0008 in group A & p < 0.0001 in group B). In Group A Percentage of abnormal tympanograms becoming normal (Type A), 12 weeks after adenoidectomy was 80%. In Group B Percentage of abnormal tympanograms becoming normal (Type A), 12 weeks after adenoidectomy was 88%. A statistically significant improvement (p < 0.0001 in both the groups) in the percentage of ears with absent stapedial reflex was observed in both groups postoperatively, with no difference between the two groups suggestive of improvement in eustachian tube function. Association of Preoperatively & Postoperatively Eustachian tube function in each group undergoing adenoidectomy was statistically significant (p < 0.0001). Both forms of adenoidectomy are effective in managing adenoid hypertrophy with tubal dysfunction causing mild conductive hearing loss and prone for OME. However, the audiological and endoscopic evaluation seems to favor Endoscopic Adenoidectomy with microdebrider over conventional adenoidectomy, and it should be therefore considered in the therapeutic management of young patients with adenoidal disease.

Endoscopic Grading, Radiological Grading and Clinical Features in Children with Chronic Adenoid Hypertrophy: A Correlational Study

To obtain a correlation between endoscopic findings, radiological findings and clinical features in children with symptomatic Chronic Adenoid hypertrophy. A cross sectional study was conducted in 42 pediatric patients (3-14 years) who visited the Department of Otorhinolaryngology in a tertiary care centre from November 2019 to April 2021 (18 months). The patients were subjected to complete history taking; ENT examination, Rigid nasal endoscopic examination, a lateral X-ray nasopharynx were performed prior to surgery after obtaining consent from the parents of the patients. The endoscopic findings were assessed using ACE grading system and the X-ray nasopharynx was assessed using Adenoid- Nasopharyngeal ratio. A male predominance was noted with mouth breathing, snoring, nasal obstruction and recurrent rhinitis as common presentation. Grade 3 hypertrophy was the most common finding in X-ray Nasopharynx (Mean ANR-0.682). Children with Grade 3 adenoid hypertrophy with more than 50% choanal obstruction and Eustachian tube abutment in nasal endoscopy were noted to be the most symptomatic clinically. A positive correlation between reduced hearing (p value-0.004) and blocked ear sensation (p value- < 0.01) with eustachian tube abutment was noted. The children with more symptoms did not show higher-grade adenoid hypertrophy radiographically in our study. The adenoid- nasopharyngeal ratio on X-ray correlated with endoscopic grading of adenoid hypertrophy (p value-0.006) and degree of choanal obstruction (p value-0.003) but not with the abutment of the eustachian tube. The endoscopic grading correlated with clinical grading, but not the X-ray grading. Hence, endoscopic grading appears to be more accurate in assessing the adenoid size and endoscopic grading is nearer to clinical grading than X-ray grading. Though, the digital X-ray nasopharynx lateral view is a more convenient method, nasal endoscopy is the gold standard method to determine whether the adenoid hypertrophy is clinically significant or not.

Eustachian Tube Dysfunction in Children with Adenoid Hypertrophy: The Effect of Intranasal Azelastine-Fluticasone Spray Treatment on Middle Ear Ventilation and Adenoid Tissue

OBJECTIVES

Eustachian tube dysfunction (ETD) is frequent in children with adenoid hypertrophy (AH). Although the most common treatment of AH is surgical removal of adenoid tissue, numerous studies have reported the efficacy of intranasal steroids. The effects of the intranasal steroid and azelastine combination on AH and ETD have not been reported before. In this study, we tried to determine the effects of 3-month intranasal Azelastine-Fluticasone dipropionate combination (Aze-Flu) treatment in children with ETD and AH.

MATERIALS AND METHODS

100 children who had open mouth sleep, snoring, and sleep apnea and were diagnosed with AH and ETD participated in this study. The mean age was 7.73 ± 2.37 (4-14 years). The rates of adenoid tissue hypertrophy and choanal occlusion were evaluated using a rigid pediatric nasal endoscope and reassessed after 3 months of Aze-Flu nasal spray treatment. The function of the Eustachian tube (ET) was evaluated before and after medical treatment using the Eustachian tube score, the Eustachian dysfunction test-7 (ETS-7) and tubomanometry (TMM).

RESULTS

The results were evaluated in 100 patients with AH and ETD. The adenoid tissue to choana rate was 82% before treatment and decreased to 37% after treatment. The ETS-7 test score was 6.36 before treatment and increased to 9.72 at the end of 3 months. Both the regression of the adenoid tissue and the improvement in the Eustachian function scores were statistically significant (p < 0.05).

CONCLUSIONS

AH significantly increases the frequency of ETD. In this study, it was observed that Aze-Flu treatment was significantly effective in both regression of the adenoid tissue and Eustachian tube dysfunction. We believe that it can be applied as an initial therapy in children with AH and associated ETD.

Impact of IL-17-producing γδ T cells on chronic otitis media induced by nontypeable Haemophilus influenzae in a mouse model

Nontypeable Haemophilus influenzae (NTHi) is considered a major pathogen underlying middle ear infection. This study aimed to investigate the impact of IL-17 on chronic otitis media (COM) induced by NTHi in mice. NTHi was inoculated into the tympanic bulla with eustachian tubal obstruction. Middle ear effusions (MEEs) and tissues were collected on days 3, 14, and at 1, 2, and 6 months after injection. The expression of interleukin-17A (IL-17A) in MEEs was significantly elevated compared to that in the control group at the translational and transcriptional levels during the experiments. The quantities of IL-17-producing γδ T cells were significantly increased compared to that in the control group during COM, but that of Th17 cells did not. Depletion of γδ T cells by anti-γδ T-cell receptor (TCR) monoclonal antibody (mAb) administration significantly decreased the bacteria counts and the concentrations of IL-1β, IL-6, IL-17A, TNF-α, and IL-10 in MEEs. Our results suggest that IL-17 may play an important role in prolonging the inflammation in the middle ear in COM and that IL-17-producing γδ T cells may contribute to the exacerbated inflammatory response in the middle ear. In this study, anti-γδ TCR mAb administration was found to improve chronic middle ear inflammatory conditions.

Tympanoplasty and adenoidectomy in children: Comparison of simultaneous and sequential approaches

Background

The authors sought to compare simultaneous and sequential tympanoplasty and adenoidectomy surgery in pediatric patients.

Methods

This retrospective single-center study included 65 children (36 males, 29 females; mean age 9.16 ± 3.82 years; range 3–17 years) requiring both tympanoplasty and adenoidectomy. Simultaneous surgeries were performed on the same day, during single general anesthesia, whereas sequential surgeries were separated at least 12 weeks. The groups were compared with regard to restoration of hearing, tympanic membrane status, and utilization of medical resources. All study participants had a 12-months follow-up period after surgery.

Results

No statistically significant differences were observed between the groups regarding pre- and post-operative ABG values and average hearing gains. However, the post-operative ABG was significantly lower than the pre-operative ABG in both groups (p<0.001). There were no significant differences between simultaneous and sequential groups with respect to complete healing rates and complications (all p>0.355). Simultaneous tympanoplasty and adenoidectomy surgery management is associated with a significantly decreased cumulative hospital stay, cumulative operating room time, and cumulative pure surgical time (all p≤0.016).

Conclusions

The results of first comparative study of simultaneous versus sequential tympanoplasty and adenoidectomy surgery managements demonstrate no advantages for the sequential approach. The same-day surgery can show the clinical outcomes comparable to those in the sequential group. The simultaneous surgery approach appears to be associated with reduced medical resources consumption. Therefore, simultaneous surgery management is an effective and safe option for children with chronic otitis media and adenoid hypertrophy.

Clustering upper airway physicals, otitis media with effusion and auditory functions in children

OBJECTIVE

Adenoid hypertrophy (AH) has been identified as a cause of otitis media with effusion (OME), which is the most common cause of childhood hearing loss. Indeed, there may be other upper airway-related predisposing factors such as, location of the adenoid, accompanying tonsillar hypertrophy (TH) and nasal septal deviation (NSD) for the development of OME. In this study, we aimed to evaluate the associations between the upper airway physicals and OME with auditory functions.

METHODS

Eighty-six ears of 43 children, aged 3-11 years were included in this prospective clinical study. Findings of otolaryngologic examinations were noted. Data of pure tone audiometry (PTA), traditional tympanometry (TT) and wideband tympanometry (WBT) parameters were collected. Cluster analysis was performed to the following variables: age, sex; the adenoid choana percentage (ACP), the presences of adenoid around torus tubarius (AATT), TH, NSD and OME; peak pressure (PP) values on TT, resonance frequencies (RF) on WBT, ambient pressure absorbance ratios (APAR) and PTA hearing thresholds.

RESULTS

Two groups of ears revealed by clustering; cluster-1 (n = 46) and cluster-2 (n = 40), at the similarity level of 0.662. The presences of AH, AATT, OME and the medians of ACP, PP, RF, WBT APARs at all frequencies except 5656 Hz and 8000 Hz, all PTA thresholds were significantly different between two clusters (p < 0.05). The lower WBT APARs and higher PTA thresholds were associated with higher levels of ACP and higher frequencies of the presence of AATT and OME in cluster-1.

CONCLUSION

There are associations between AH, AATT and OME together with decline in hearing and SEA. Whereas, TH and NSD are not related to the formation of clusters and they are insignificant factors.

Detection of respiratory viruses in primary cholesteatoma tissues

Cholesteatomas are frequent middle ear benign tumors of unknown etiology. Infectious agents have been considered as possible contributing factors in the pathogenesis of cholesteatomas. Aiming to investigate the presence of respiratory viruses in primary cholesteatoma tissues, 26 formalin-fixed paraffin-embedded primary cholesteatoma tissues obtained from patients seen at the of the Clinical Hospital of the University of São Paulo School of Medicine, in Ribeirão Preto, Brazil were tested by real-time polymerase chain reaction (PCR). Considering the PCR results, 35% of the tissues were positive for human rhinovirus (HRV), 15.3% for human enterovirus (EV), 3.8% for human metapneumovirus (HMPV), and 3.8% for human bocavirus (HBoV). Serial immunohistochemistry for virus antigens and cell surface markers evidenced that the viruses were associated with fibroblasts, dendritic cells, macrophages, B lymphocytes, CD4⁺ , and CD8⁺ T lymphocytes. These findings indicate for the first time the presence of active respiratory virus infection in primary cholesteatoma tissues, suggesting that persisting virus infection in the middle could play a role in the pathogenesis and evolution of cholesteatomas.

Adenotonsillectomy Does not Alter the Risk of Upper Airway Infections in Children

OBJECTIVE

Given the conflicting evidence regarding adenotonsillectomy and the risk of upper airway infections (UAIs), including acute pharyngitis (APT), rhinosinusitis (ARS), and otitis media (AOM), we evaluated the risk of developing UAIs following adenotonsillectomy in a childhood population.

METHODS

In this population-based follow-up study, we used data from the National Health Insurance Service-National Sample Cohort. The adenotonsillectomy group (n = 2,377) included patients aged <10 years who underwent an adenotonsillectomy. For every patient with APT (n = 2,309), ARS (n = 2,308), and AOM (n = 2,207) who had an adenotonsillectomy, four participants were randomly selected for the control groups (n = 9,204, n = 9,196, and n = 8,788, respectively) using propensity score matching. The number of postoperative hospital visits for UAIs was recorded for 1 to 9 years, and the equivalence test was used to compare the number of visits between the adenotonsillectomy and control groups.

RESULTS

There were no significant differences in the incidence of APT, ARS, or AOM at the margin of equivalence of difference (-0.5 < 95% confidence interval of difference < 0.5) between the two groups from postoperative year 1 to year 9. The hospital visits for these diseases gradually decreased over time in both groups. There was a significant decrease in the number of visits for APT, ARS, and AOM in the 5-9 years age group when compared with those in the <4 years age group (P < .01).

CONCLUSION

Our results suggest that adenotonsillectomy does not alter the frequency of UAIs in children.

LEVEL OF EVIDENCE

N/A Laryngoscope, 2021.

Planar cell polarity governs the alignment of the nasopharyngeal epithelium in mammals

Planar cell polarity (PCP) signalling specifies the orientation of epithelial cells and regulates directional beating of motile cilia of multiciliated epithelial cells. Clinically, defects in cilia function are associated with nasopharyngeal symptoms. The polarity of the nasopharyngeal epithelium is poorly understood. Here, we demonstrated PCP in the nasopharyngeal epithelium. Multiciliated cells (MCCs) were uniformly aligned with their long axis parallel to the tissue axis of the nasopharynx (NP). In addition, PCP proteins exhibited an asymmetrical localisation between adjacent cells. Motile cilia were uniformly aligned in the same direction within both individual cells and neighbouring cells, which manifested as cilial polarity in MCCs. Mutation of Vangl2, a mammalian homologue of the Drosophila PCP gene, resulted in significant disruption of the orientation of epithelial cells. Finally, keratin-5-positive basal cells constantly replenished the luminal ciliated cells; the new dynamic ciliated cells were also oriented parallel to the tissue axis. These results indicate a role for the PCP pathway in the uniform orientation of dynamically replenished epithelial cells in the NP.

Eustachian Tube Dysfunction in Children With Adenoid Hypertrophy: The Role of Adenoidectomy for Improving Ear Ventilation

INTRODUCTION

To our knowledge, few papers have addressed preoperative evaluation of the impact of adenoid hypertrophy (AH) on the pathogenesis of eustachian tube dysfunction (ETD) in children with otitis media with effusion (OME).

AIM

The aim of this study was 2-fold: first, to evaluate ETD using tubomanometry and Eustachian Tube Score 7 (ETS-7), in a group of children having AH; second, to assess the clinical impact of adenoidectomy on the ETD of these patients.

METHODS

Fifty patients, aged 4 to 15 years, underwent adenoidectomy based on various parameters: size of the adenoids causing canal obstruction (grades 1-4), the presence of OME, and recurrent episodes of rhinosinusitis. The function of the eustachian tube was evaluated using ETS-7 before and after surgical treatment. The patients were followed up for 6 months.

RESULTS

Forty children presented ETD. Of these, 36 had a grade 4 AH. The preoperative mean value for ETS-7 was 6.62. The mean postoperative ETS-7 score showed a value of 9.60 with a statistical difference compared to the preoperative value (P = .0015).

CONCLUSIONS

Adenoid hypertrophy has a high impact on the frequency of ETD. In the patients observed in the present study, the ETS-7 score appeared to be a valid tool for assessing ETD both preoperatively and postoperatively. Adenoidectomy seemed to be effective in improving ETD as well as middle ear ventilation.

Correlation Between Adenoid Hypertrophy, Tympanometry Findings, and Viscosity of Middle Ear Fluid in Chronic Otitis Media With Effusion, Southern Oman

Otitis media with effusion is a common cause of diminished hearing in children younger than 12 years. Hypertrophy of adenoids is one of the commonest etiologies of this condition. It has been mentioned that with increased size of the adenoid tissue, the more likely the incidence of fluid in the middle ear. The aim of this study was to find whether there is a correlation between adenoid size, tympanometric findings, and type of fluid in the middle ear irrespective of disease duration. This is a prospective study done on 100 pediatric patients (12 years and less) presented with chronic otitis media with effusion (COME) and adenoid hypertrophy from July 2015 till July 2017. Cases with tympanometry evidence of COME (B, Cs) and adenoid hypertrophy seen by nasal endoscopy were included. Adenoid size was graded and correlated with the type of tympanometry and type of fluid in the middle ear. Sixty male children and 40 female children were involved. Age ranged from 3 to 12 years with a mean of 7.19 ± 2.489 years. Highly significant relation existed between grade 4 adenoid hypertrophy and mucoid nature of middle ear fluid (P value = .000). There is a highly significant relation between adenoid hypertrophy grade Ⅳ and type B tympanometry. There is a highly significant relation between adenoid size and nature of middle ear fluid irrespective of the duration of complaints, where grade Ⅳ adenoid hypertrophy showed more increase in middle ear effusion viscosity making adenoid size a very important predictor for the tympanometry type and the nature of the fluid in the middle ear.

The effect of adenoid hypertrophy on hearing thresholds in children with otitis media with effusion

INTRODUCTION

Otitis media with effusion is common middle ear mucosa disease that can cause hearing loss in children. Adenoid hypertrophy can cause recurrent acute otitis media in addition to otitis media with effusion as a result of eustachian tube dysfunction and primary infection focus. The aim of this study was to investigate the effect of adenoid hypertrophy on the hearing threshold in children suffering from otitis media with effusion.

METHODS

Children of school age with otitis media with effusion were included in the study. The size and location of the adenoid tissue were determined by examination with a flexible endoscope. Four adenoid size groups were determined according to the percentage of choanal closure. The coverage was 0-25% in the first group, 26-50% in the second group, 51-75% in the third group and 76-100% in the 4th group. The location of the adenoid tissue in the nasopharynx was divided into three groups. In group A, the adenoid tissue was not in contact with torus tubarius. In group B, the adenoid tissue was in contact with the torus tubarius but did not cover it. In group C, the adenoid tissue covered the torus tubarius completely. Bone and air conduction thresholds were determined using standard procedures. The statistical relationship between the size and location of adenoid tissue and the hearing thresholds was investigated.

RESULTS

The study was conducted with the 88 ears of 50 children aged 5-15 years. The median values of mean air conduction thresholds at 500 Hz, 1000 Hz, and 2000 Hz in the adenoid tissue size groups 1-4 were 22 dB HL, 20 dB HL, 15 dB HL, and 20 dB HL respectively. The median values of the mean air conduction thresholds were 20 dB HL, 20 dBHL and 18 dB HL in the adenoid location group A-C, respectively. No significant correlation was found between the groups (p:0.213) and the relevant hearing values (p:0.670). Type B tympanogram was identified in 46 ears and type C tympanogram in 42 ears. The mean hearing thresholds were significantly higher in the ears with a type B tympanogram in the otitis media with effusion cases. (P < 0.001).There was no significant correlation between the duration of effusion and the adenoid size (p:0.931), adenoid location (p:0.626) and hearing threshold (p:0.815).

CONCLUSION

We concluded that adenoid tissue size and location have no effect on hearing thresholds and the duration of effusion in otitis media with effusion. We suggest caution before deciding on adenoidectomy in otitis media with effusion cases. Adenoidectomy should not be performed in children over 4 years of age unless there is a definite indication such as nasal obstruction or chronic adenitis.

Prevalence and nature of hearing loss in a cohort of children with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) may cause injury to any organ, including the auditory system. Although the association of SCD and hearing loss has been described, the nature of this complication is unknown. We sought to establish the prevalence and nature of hearing loss in a referred cohort of children with SCD and to identify correlating disease- or treatment-associated factors.

PROCEDURE

We conducted a retrospective review of patients with SCD < 22 years of age who had hearing evaluations between August 1990 and December 2014. Demographics, audiograms, and disease and treatment variables were analyzed.

RESULTS

Two hundred and ten audiograms among 81 patients were reviewed, and 189 were evaluable. Seventy-two children constituted the referred cohort. Fourteen (19.4%) had hearing loss documented on at least one audiogram. Seven (9.7%) patients had only conductive hearing loss, and the loss persisted for up to 10.3 years. The median age of first identification was eight years. Six (8.3%) patients had hearing loss that was at least partially sensorineural. One patient's hearing loss was ambiguous. All sensorineural hearing losses were unilateral and 4/6 patients had prior documented normal hearing, indicating acquired loss. No correlations were identified.

CONCLUSIONS

Both conductive and sensorineural hearing losses are more prevalent in our study population than those observed in the general pediatric population. In children with SCD, sensorineural hearing loss appears to be acquired and unilateral. Conductive hearing loss was identified in older children and can persist. Serial screening is needed for early detection and more prompt intervention in this population.

Presentation and eustachian tube function test results in children evaluated at a specialty clinic

OBJECTIVES/HYPOTHESIS

Interest in eustachian tube (ET) dysfunction (ETD) has increased with the recent Food and Drug Administration approval of a new device for balloon dilation of the ET (BDET) in adults. However, children have been receiving BDET treatment with ET-specific or sinus balloons around the world and off-label in the United States for years. It is important, therefore, to understand the manifestations of and methods to verify ETD in children.

STUDY DESIGN

Retrospective cross-sectional study.

METHODS

This is a retrospective study of clinical presentations and results of ET function (ETF) tests in children referred to the ETD clinic. An otorhinolaryngology exam, nasopharyngeal videoendoscopy of the ET orifices during swallow and maneuvers, and ETF tests, including inflation deflation, forced response test, and pressure chamber tests, were performed as applicable.

RESULTS

Data for 30 children aged 6.2 to 17.3 years (mean = 12.9 ± 2.8 years) were analyzed. Of 60 ears, 19 (31.7%) had an intact tympanic membrane (TM), 16 (26.7%) had a patent and two had a blocked ventilation tube, and 23 (38.3%) had a TM perforation. Endoscopy of the nasopharynx revealed a large amount of secretions in 19/45 (42.2%); ET orifices and mucosal inflammation in 22/45 (48.8%); a large amount of adenoid tissue in the fossa of Rosenmuller was noted in 21/45 (46.7%). ETF tests revealed abnormal active function in 43/54 ears (79.6%) and abnormal passive function in 40/54 ears (74.1%).

CONCLUSIONS

ETD in children is often associated with residual or regrowth of adenoids and inflammation. Caution should be taken assigning a uniform phenotype and treatment prior to thorough evaluation and testing.

LEVEL OF EVIDENCE

4 Laryngoscope, 129:1218-1228, 2019.

Relation between adenoid size and otitis media with effusion

AIMS

This study compares the efficacy of adenoidectomy on otitis media with effusion (OME) in patients with different size of adenoids and the connection between differently sized adenoids and middle ear effusion.

MATERIAL AND METHODS

Children with a history of at least 3 months' OME underwent adenoidectomy and myringotomy without the insertion of a tympanostomy tube. Treatment assignment was stratified by adenoids' size causing choanal obstruction (grade I-III) and according to Eustachian tube ostium obstruction (grade A-C). The subjects were followed for 12 months.

RESULTS

Adenoidectomy was significantly more effective in children with adenoids in contact with torus tubarius (grade B, C) compared to those with small adenoids without contact (P<0.001). The volume of the adenoids was irrelevant (P=0.146). The size of adenoids did not affect the viscosity of the middle ear secretion. The distribution of mucous and serous secretion was not dependent on the size of adenoids; the efficacy of adenoidectomy was 82% in mucous as well as serous secretion.

CONCLUSION

The relation between adenoids and torus tubarius is more important than the volume of the adenoids. The viscosity of middle ear fluids (serous or mucous) did not influence the rate of treatment efficacy.

Intranasal Steroid Use for Otitis Media with Effusion: Ongoing Opportunities for Quality Improvement

Objectives Our objectives were (1) to assess patterns of intranasal steroid administration when otitis media with effusion (OME) has been diagnosed in children, (2) to investigate whether usage varies according to visit setting, and (3) to determine if practice gaps are such that quality improvement could be tracked. Study Design Cross-sectional analysis of an administrative database. Subjects and Methods National Ambulatory and Hospital Ambulatory Medical Care Surveys, 2005 to 2012; univariate, multivariate, and stratified analyses of intranasal steroid usage were performed. The primary outcome was intranasal steroid administration, and the primary predictor was a diagnosis of OME. The impact of location of service was also analyzed. Results Data representing 1,943,177,903 visits demonstrated that intranasal steroids were administered in 10.0% of visits in which OME was diagnosed, in comparison to 3.5% of visits in which OME was not diagnosed (univariate odds ratio, 3.07; 95% confidence interval [CI], 1.85-5.08; P < .001). After adjusting for age, sex, race/ethnicity, and other confounding conditions, multivariate analysis demonstrated that OME remained associated with an increase in intranasal steroid usage (odds ratio, 3.58; 95% CI, 1.60-8.01; P = .002). This practice pattern was more prevalent in the ambulatory office setting (risk difference 6.6%, P < .001) and less seen in a hospital-based office or emergency department. Conclusion Despite randomized controlled trials showing a lack of efficacy for isolated OME, nasal steroids continue to be used in treating children with OME in the United States. Related quality improvement opportunities to prevent usage of an ineffective treatment exist.

The pathogens profile in children with otitis media with effusion and adenoid hypertrophy

Objectives

To evaluate the presence of viruses and bacteria in middle ear and adenoids of patients with and without otitis media with effusion (OME).

Methods

Adenoid samples and middle ear washes (MEW) were obtained from children with OME associated with adenoid hypertrophy undergoing adenoidectomy and tympanostomy, and compared to those obtained from patients undergoing cochlear implant surgery, as a control group. Specific DNA or RNA of 9 respiratory viruses (rhinovirus, influenza virus, picornavirus, syncytial respiratory virus, metapneumovirus, coronavirus, enterovirus, adenovirus and bocavirus) and 5 bacteria (S. pneumoniae, H. influenzae, M. catarrhalis, P. aeruginosa and S. aureus) were extracted and quantified by real-time PCR.

Results

37 OME and 14 cochlear implant children were included in the study. At the adenoid, virus and bacteria were similarly detected in both OME and control patients. At the middle ear washes, however, a higher prevalence of bacteria was observed in patients with OME (p = 0.01). S. pneumoniae (p = 0.01) and M. catarrhalis (p = 0.022) were the bacteria responsible for this difference. Although total virus detection was not statistically different from controls at the middle ear washes (p = 0.065), adenovirus was detected in higher proportions in adenoid samples of OME patients than controls (p = 0.019).

Conclusions

Despite both OME and control patients presented similar rates of viruses and bacteria at the adenoid, children with OME presented higher prevalence of S. pneumonia, M. catarrhalis in middle ear and adenovirus in adenoids when compared to controls. These findings could suggest that these pathogens could contribute to the fluid persistence in the middle ear.

Diagnostic Accuracy of Radiology and Endoscopy in the Assessment of Adenoid Hypertrophy

Aim

To clarify the diagnostic accuracy of the lateral X-ray of nasopharynx, and the flexible nasopharyngoscopy in the assessment of adenoid hypertrophy, with the preoperative rigid nasal endoscopic observation, as it was considered as a reference standard guide.

Materials and methods

This is a prospective observational study that included 80 children who planned to undergo adenoidectomy due to the symptoms found related to adenoid hypertrophy. All the children underwent a relevant clinical history and full ear, nose, and throat (ENT) examination, and the grading of adenoid hypertrophy was done preoperatively with the lateral X-ray of the nasopharynx and the flexible nasopharyngoscopy. These findings were analyzed and compared with the peroperative rigid nasal endoscopic assessment of adenoid hypertrophy, which was considered as a reference guide.

Results

There were 44 boys (55%) and 36 girls (45%), with mean age of 5.176 (±1.873) years, and the highest frequency of adenoid hypertrophy was found in the age group of 4 to 6 years (62.45%); the most common grade of the adenoid size in all the types of the assessment was grade 3. The assessment of adenoid grading by both flexible and peroperative rigid nasal endoscopy versus radiology was statistically significant, with p value of 0.0001, while the adenoid grading between flexible and peroperative rigid nasal endoscopic assessment was almost comparable, as no significant difference was found, with p value of 0.46.

Conclusion

Flexible nasopharyngoscopy was a more reliable diagnostic tool in the assessment of the adenoid size than lateral nasopharyngeal X-ray, as it correlates well with peroperative rigid nasal endoscopic finding.

How to cite this article

Dawood MR, Khammas AH. Diagnostic Accuracy of Radiology and Endoscopy in the Assessment of Adenoid Hypertrophy. Int J Otorhinolaryngol Clin 2017;9(1):6-9.

Accumulation of Regulatory T Cells and Chronic Inflammation in the Middle Ear in a Mouse Model of Chronic Otitis Media with Effusion Induced by Combined Eustachian Tube Blockage and Nontypeable Haemophilus influenzae Infection

Nontypeable Haemophilus influenzae (NTHi) is associated with chronic otitis media (COM). In this study, we generated a murine model of COM by using eustachian tube (ET) obstruction and NTHi (10(7) CFU) inoculation into the tympanic bulla, and we investigated the relationship between regulatory T cells (Treg) and chronic inflammation in the middle ear. Middle ear effusions (MEEs) and middle ear mucosae (MEM) were collected at days 3 and 14 and at 1 and 2 months after inoculation. Untreated mice served as controls. MEEs were used for bacterial counts and to measure the concentrations of cytokines. MEM were collected for histological evaluation and flow cytometric analysis. Inflammation of the MEM was prolonged throughout this study, and the incidence of NTHi culture-positive MEE was 38% at 2 months after inoculation. The levels of interleukin-1β (IL-β), tumor necrosis factor alpha, IL-10, and transforming growth factor β were increased in the middle ear for up to 2 months after inoculation. CD4(+) CD25(+) FoxP3(+) Treg accumulated in the middle ear, and the percentage of Treg in the MEM increased for up to 2 months after inoculation. Treg depletion induced a 99.9% reduction of bacterial counts in MEEs and also significantly reduced the ratio of NTHi culture-positive MEE. The levels of these cytokines were also reduced in MEEs. In summary, we developed a murine model of COM, and our findings indicate that Treg confer infectious tolerance to NTHi in the middle ear.

Does the type of rhinitis influence development of otitis media with effusion in children?

Otitis media with effusion (OME) is characterized by the presence of fluid in the middle ear cavity behind an intact eardrum and is considered a multifactorial condition with Eustachian tube dysfunction as the underlying pathophysiologic condition. One of the most debated causes of OME is allergy, in particular allergic rhinitis. The aim of this paper is to review the role of rhinitis in the development of OME and in particular the role of both allergic (AR) and non-allergic rhinitis (NAR). Most of the recent literature confirms the role of AR in the development of OME, while there are few reports on the role of NAR. In non-allergic children affected by obstructive adenoid hypertrophy, the presence of mast cells in the nasal smear was associated with a high risk of developing a chronic OME.

The protective effect of adenoidectomy on pediatric tympanostomy tube re-insertions: a population-based birth cohort study

OBJECTIVES

Adenoidectomy in conjunction with tympanostomy tube insertion for treating pediatric otitis media with effusion and recurrent acute otitis media has been debated for decades. Practice differed surgeon from surgeon. This study used population-based data to determine the protective effect of adenoidectomy in preventing tympanostomy tube re-insertion and tried to provide more evidence based information for surgeons when they do decision making.

STUDY DESIGN

Retrospective birth cohort study.

METHODS

This study used the National Health Insurance Research Database for the period 2000-2009 in Taiwan. The tube reinsertion rate and time to tube re-insertion among children who received tympanostomy tubes with or without adenoidectomy were compared. Age stratification analysis was also done to explore the effects of age.

RESULTS

Adenoidectomy showed protective effects on preventing tube re-insertion compared to tympanostomy tubes alone in children who needed tubes for the first time (tube re-insertion rate 9% versus 5.1%, p = 0.002 and longer time to re-insertions, p = 0.01), especially those aged over 4 years when they had their first tube surgery. After controlling the effect of age, adenoidectomy reduced the rate of re-insertion by 40% compared to tympanostomy tubes alone (aHR: 0.60; 95% CI: 0.41-0.89). However, the protective effect of conjunction adenoidectomy was not obvious among children with a second tympanostomy tube insertion. Children who needed their first tube surgery at the age 2-4 years were most prone to have tube re-insertions, followed by the age group of 4-6 years.

CONCLUSIONS

Adenoidectomy has protective effect in preventing tympanostomy tube re-insertions compared to tympanostomy tubes alone, especially for children older than 4 years old and who needed tubes for the first time. Nonetheless, clinicians should still weigh the pros and cons of the procedure for their pediatric patients.

Otitis media with effusion: an effort to understand and clarify the uncertainties

Otitis media with effusion--defined as the accumulation of middle-ear effusion behind an intact tympanic membrane without signs or symptoms of acute infection--is one of the most common causes of hearing loss in children in developed countries, potentially leading to language deficits. Although treatment of chronic or relapsing otitis media with effusion is considered imperative, none of the preventative or nonsurgical management measures currently available have proven effective. Tympanostomy tube placement remains the recommended treatment option for high-risk children or for cases of unresponsive otitis media with effusion. This can be attributed to the uncertainties surrounding its pathogenesis. Multiple factors and several possible pathogenetic models have been proposed to explain the production and persistence of middle-ear effusion; only a few of them are supported by sufficient evidence. In this review, the authors will present current knowledge on the pathogenesis, consequences, diagnosis and management of otitis media with effusion. An effort will be made to clarify those aspects sufficiently supported by evidence-based studies, and to underline those that remain unfounded.

A study of the role of different forms of chronic rhinitis in the development of otitis media with effusion in children affected by adenoid hypertrophy

OBJECTIVE

The aim of the present study was to evaluate the role of the different forms of chronic rhinitis in the pathogenesis of otitis media with effusion in children affected by obstructive adenoid hypertrophy.

METHODS

81 patients, aged between 4 and 15 years (mean age of 6.9 years), affected by obstructive adenoid hypertrophy were evaluated. All patients underwent accurate history taking, physical examination with endoscopy of the nasopharynx, skin prick test, nasal cytology and hearing evaluation.

RESULTS

Nasal citology showed that 21% of patients had a non-allergic rhinitis (NAR) subtype, 17.4% NAR overlapping with infectious rhinitis (IR), 29.6% IR, 4.9% allergic rhinitis (AR), 2.5% AR overlapping with IR and the remaining 24.6% a negative cytology. The presence of OME was positively correlated with neutrophils (p = 0.01) and mast cells (p = 0.022), while it was negatively correlated with the presence of eosinophils (p = 0.02) and bacteria (p = 0.02).

CONCLUSIONS

A chronic rhinitis was present in more than 70% of children with AH and 60% of them showed OME. Nasal cytology together with SPT showed that AR was rarely present in this group of children, while the mast-cells and neutrophils positively correlated with OME.

Recurrent tube insertion for chronic otitis media with effusion in children over 6 years

OBJECTIVE

The purpose of this study is to identify the clinical characteristics of children above 6 years of age with chronic otitis media with effusion (COME) who have required pressure equalizing tube (PET) insertions.

METHODS

A retrospective chart review was performed of all children above the age of 6 years, who underwent PET insertion due to chronic OME, between 2000 and 2009 at a tertiary care institution. Children were also divided into those with a single PET and those with ≥ 2 PET. Comparison of various characteristics between the two groups was undertaken.

RESULTS

290 children were identified as having at least one PET insertion after the age of 6 years. 45.5% of the children underwent a single PET insertion while 54.5% underwent 2 procedures or more. No significant gender-based difference was observed. In those patients requiring ≥ 2 PET, 65.2% also underwent tonsillectomy and/or adenoidectomy compared to only 53.8% of children with a single PET intervention (p<0.05). Asthma, trisomy 21 and cleft palate, were more common in those children who had undergone ≥ 2 PET (p<0.001, p<0.01 and p<0.05, respectively).

CONCLUSIONS

Children above 6 years of age who have undergone ≥ 2 PET insertions for COME demonstrated an increased rate of tonsillectomy and adenoidectomy. Trisomy 21, cleft palate and particularly, asthma, were also found to be risk factors for COME necessitating ≥ 2 PET insertions.

Differential expression of Immunoglobulin A in the adenoids of children with and without exudative otitis media

OBJECTIVE

To evaluate the variation of Immunoglobulin A (IgA) levels in the adenoids of children with otitis media with effusion (OME) and the correlation to age.

METHODS

A total of 129 children were enrolled in this study, including 60 children with OME and 69 children without OME. The children were divided into two groups according to age: aged ≤ 4 years (33 children with OME and 39 children without OME) and aged > 4 years (27 children with OME and 30 children without OME). The samples were collected from hypertrophic adenoids, which could cause obstructive symptoms and/or OME. The IgA concentrations were analyzed by immunohistochemistry in the two groups.

RESULTS

The expression of IgA in the adenoids of children ≤ 4 years was significantly lower than in those aged > 4 years. Among children > 4 years, lower levels of IgA in the adenoids were observed in patients with OME than in patients without OME. However, no statistically significant differences in the IgA levels were found between patients aged ≤ 4 years with and without OME.

CONCLUSIONS

The differential expression of IgA in the adenoids between patients with and without OME was correlated to age.

Adenoid reservoir for pathogenic biofilm bacteria

Biofilms of pathogenic bacteria are present on the middle ear mucosa of children with chronic otitis media (COM) and may contribute to the persistence of pathogens and the recalcitrance of COM to antibiotic treatment. Controlled studies indicate that adenoidectomy is effective in the treatment of COM, suggesting that the adenoids may act as a reservoir for COM pathogens. To investigate the bacterial community in the adenoid, samples were obtained from 35 children undergoing adenoidectomy for chronic OM or obstructive sleep apnea. We used a novel, culture-independent molecular diagnostic methodology, followed by confocal microscopy, to investigate the in situ distribution and organization of pathogens in the adenoids to determine whether pathogenic bacteria exhibited criteria characteristic of biofilms. The Ibis T5000 Universal Biosensor System was used to interrogate the extent of the microbial diversity within adenoid biopsy specimens. Using a suite of 16 broad-range bacterial primers, we demonstrated that adenoids from both diagnostic groups were colonized with polymicrobial biofilms. Haemophilus influenzae was present in more adenoids from the COM group (P = 0.005), but there was no significant difference between the two patient groups for Streptococcus pneumoniae or Staphylococcus aureus. Fluorescence in situ hybridization, lectin binding, and the use of antibodies specific for host epithelial cells demonstrated that pathogens were aggregated, surrounded by a carbohydrate matrix, and localized on and within the epithelial cell surface, which is consistent with criteria for bacterial biofilms.

Relationship between pharyngeal conformation and otitis media with effusion in Cavalier King Charles spaniels

Otitis media with effusion (OME) is a common incidental finding in otherwise normal Cavalier King Charles spaniels (CKCS). In this study, measurements made on MRI were used to determine whether there was an association between OME and brachycephalic conformation. The results confirm that association and also demonstrate that, in CKCS, greater thickness of the soft palate and reduced nasopharyngeal aperture are significantly associated with OME. These results suggest that auditory tube dysfunction and OME may represent a previously overlooked consequence of brachycephalic conformation in dogs.

Pathophysiology of nasal congestion

Nasal congestion is a common symptom in rhinitis (both allergic and nonallergic), rhinosinusitis and nasal polyposis. Congestion can also be caused by physical obstruction of nasal passages and/or modulation of sensory perception. Mucosal inflammation underlies many of the specific and interrelated factors that contribute to nasal congestion, as well as other symptoms of both allergic rhinitis and rhinosinusitis. A wide range of biologically active agents (eg, histamine, tumor necrosis factor-α, interleukins, cell adhesion molecules) and cell types contribute to inflammation, which can manifest as venous engorgement, increased nasal secretions and tissue swelling/edema, ultimately leading to impaired airflow and the sensation of nasal congestion. Inflammation-induced changes in the properties of sensory afferents (eg, expression of peptides and receptors) that innervate the nose can also contribute to altered sensory perception, which may result in a subjective feeling of congestion. Increased understanding of the mechanisms underlying inflammation can facilitate improved treatment selection and the development of new therapies for congestion.

Fluorescence "in situ" hybridization for the detection of biofilm in the middle ear and upper respiratory tract mucosa

Most chronic bacterial infections are associated with biofilm formation wherein the bacteria attach to mucosal surfaces, wound tissue, or medical device surfaces in the human body via the formation of an extracellular matrix. Biofilms assume complex three-dimensional structures dependent on the species, the strain, and the prevailing environmental conditions and are composed of both the bacteria and the extracellular slime-like matrices, which surround the bacteria. Bacteria deep in the biofilm live under anaerobic conditions and must use alternatives to O(2) as a terminal electron acceptor. Thus, the metabolic rates of these deep bacteria are greatly reduced, which renders them extremely resistant to antibiotic treatment, and for reasons not clearly understood, it is often very difficult to culture biofilm bacteria using traditional microbiologic techniques. To directly identify and visualize biofilm bacteria in a species-specific manner, we developed a confocal laser scanning microscopy (CLSM)-based 16S rRNA fluorescence in situ hybridization (FISH) protocol, to find biofilm bacteria in middle ear and upper respiratory tract mucosa, which preserves the three-dimensional structure of the biofilm and avoids the use of traditional culture techniques.

Prospective, randomized, single-blind, controlled study to compare two methods of performing adenoidectomy

OBJECTIVE

To compare adenoidectomy using suction-diathermy ablation to curettage adenoidectomy with respect to operative time and adenoid regrowth at 6 months after surgery.

STUDY DESIGN

A prospective, randomized, single-blind, study to compare two methods of performing adenoidectomy. A group of 100 children, undergoing adenoidectomy alone or in combination with tonsillectomy, were randomized into two groups and underwent either suction diathermy or curettage adenoidectomy by a single surgeon.

SETTING

A tertiary care Paediatric Hospital.

METHOD

Indication for surgery, adenoidal size, duration of surgery and complications were recorded and compared. Six-month follow-up was conducted and adenoidal size and symptom status were recorded and compared. Statistical analysis was performed using Microsoft Excel.

RESULTS

One hundred patients participated in this study and underwent adenoidectomy alone or adenotonsillectomy. Ninety-two patients returned for follow-up and 91 patients completed the study. The two treatment groups were well matched for age and gender. The main indications for both groups were snoring, nasal obstruction and obstructive sleep apnoea. For adenoidectomy alone there was no significant difference in duration of surgery between the curette and suction diathermy groups. When performing tonsillectomy and adenoidectomy together suction diathermy took significantly longer to complete than curettage (P<0.001). Overall 96% of patients' symptoms had either improved or resolved. The post-operative comparison at 6 months showed a significant difference in the residual adenoidal size between the two groups, the suction diathermy group being generally smaller than the curettage group.

CONCLUSIONS

Suction diathermy was better at reducing the adenoidal size 6 months after surgery. Although the difference in size was statistically significant it did not seem to be of clinical significance.

[Endoscopic adenotomy--clinical assessment of value and safety--an own experience]

High number of performed adenotomies inclines ENT surgeons to introduce more and more satisfying concerning safety, accuracy and results predictability surgical techniques. The aim of our study was to assess the value and safety of an endoscopic surgical technique. The study was performed on 768 patients aged 7 months - 14 years. Group A (I) consisted of 453 patients on whom adenotomy was performed with use of Beckmann adenotome. Group B (II) consisted of 315 patients operated under endoscope control with the use of Jurasz forceps. An endoscopic technique gives remarkable decrease of intraoperative blood loss and eliminates post op bleedings, what increases patients safety. Low aggressiveness of an endoscopic technique compared to classic decreases incidents of undesirable post adenotomy signs and symptoms. In authors opinion, the results obtained during study, definitely prove the superiority of endoscopic technique--it is worth of introducing into daily surgical practice.

The role of free oxygen radicals on the development of otitis media with effusion

OBJECTIVE

The purpose of this study was to determine if free oxygen radicals (FORs) and antioxidant enzyme activities have some role in pathogenesis of otitis media with effusion (OME) in children with adenoid hyperplasia.

METHODS

Seventy-four patients were enrolled in three groups of this study. The study group (Group I) included 26 patients who had adenoidectomy with ventilation tube placement due to chronic OME. The control adenoid group (Group II) consisted of 28 age-matched patients who had adenoidectomy without ventilation tube insertion. Twenty children were included in the healthy control group (Group III). Erythrocyte malondialdehyde (MDA) levels, superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px) enzyme activities were investigated in the venous blood sample.

RESULTS

Erythrocyte MDA level and GSH-Px enzyme activity in the blood samples of study group (Group I) were significantly higher than those of Group II and Group III (P < 0.05). SOD enzyme activity in the blood samples of Group I was significantly lower than Group II (P < 0.05), and were significantly higher than Group III (P < 0.05). CAT enzyme activity of Group I was significantly lower than that of Group III (P < 0.05). However, there was no statistically significant difference between Group I and Group II regarding CAT antioxidant enzyme activity (P < 0.05).

CONCLUSIONS

The inflammation of the middle ear increases the level of FORs in erythrocyte. FOR level is normally maintained at a steady state by antioxidant enzymes. When the antioxidant defense system is weakened, the increased FORs may contribute to OME formation. We supposed that, antioxidant vitamins C and E, and scavenger enzymes such as CAT, SOD and GSH-Px may be added in the management of OME.

Adenoidectomy: selection criteria for surgical cases of otitis media

OBJECTIVE

Nasopharyngeal adenoids may serve as a mechanical obstruction to the eustachian tube and contribute to the pathophysiology of otitis media (OM). The purpose of this study was to determine whether abutment of adenoids laterally against the torus tubaris affects the outcome of patients requiring pressure equalization tubes (PET) for OM.

STUDY DESIGN

Randomized, controlled, prospective clinical trial.

METHOD

Patients requiring PET for recurrent acute OM or OM with persistent effusion were randomized into two groups: 1) PET placement and 2) PET placement and adenoidectomy, regardless of whether the adenoids were abutting or not abutting the torus tubaris. Patients were followed for a minimum of 1 year to determine rate of treatment failure, defined as recurrence of acute OM (>3 times/year), OM with effusion, or reinsertion of PET.

RESULTS

Of the 34 patients in the abutting group, 16 patients underwent only PET insertion, of whom 8 (50%) failed, whereas 18 patients had combined PET placement and adenoidectomy, of whom 3 (17%) failed. There was a statistical difference between these two groups (P < 05). Of the 29 patients in the nonabutting group, 24 patients underwent only PET insertion, of whom 9 (37.5%) failed, whereas 5 patients underwent combined PET placement and adenoidectomy, of whom 2 (40%) failed. There was no statistical difference between these two groups (P =.92).

CONCLUSION

This study demonstrates that the position of hypertrophied adenoids may alter the final otologic outcome of patients requiring PET insertion for OM. Patients with adenoids abutting the torus tubaris may benefit most from an adjuvant adenoidectomy.

The risk of adenoid hypertrophy in children with allergic rhinitis

BACKGROUND

Adenoid hypertrophy (AH) may cause significant morbidity in children but its relationship to allergic rhinitis (AR) has not been studied.

OBJECTIVE

To determine the risk factor of AH in patients with AR.

METHODS

We studied 315 children (ages 1 to 18 years) who had AH and AR. We compared them with 315 age-matched controls who had AR alone. To identify risk factors, they were divided into four groups according to age and clinical parameters, including the prevalence of otitis media, sinusitis, lower respiratory infection, exposure to smoking, sleep disorders, use of antihistamine/decongestants, and results of allergy skin testing.

RESULTS

The prevalence of upper or lower respiratory infections was higher in the group with AR and AH, but not in all age groups. A high prevalence of exposure to smoking and skin test reactivity against house dust mites were found in both groups. However, the prevalence of positive reactivity to molds was significantly higher in the group with AH and AR (P ranged from 0.013 to <0.0001 and the relative risk ranged from 1.609 to 2.375). Further, the risk of AH was positively correlated with number of skin test reactivity to mold spores (P ranged from 0.0035 to 0.0001). Positive skin test reactivity to animal danders or seasonal allergens failed to predict the risk of AH.

CONCLUSIONS

Sensitivity to mold allergens is an important risk factor for AH in children with AR; therefore, early prevention of exposure to molds may help reduce occurrence of AH.

The role of adjuvant adenoidectomy and tonsillectomy in the outcome of the insertion of tympanostomy tubes

BACKGROUND

Otitis media is the most common medical problem in young children. The usual surgical treatment is myringotomy with insertion of tympanostomy tubes. There is debate about the usefulness of concomitant adenoidectomy or adenotonsillectomy. We examined the effects of these adjuvant procedures on the rates of reinsertion of tympanostomy tubes and rehospitalization for conditions related to otitis media.

METHODS

Using hospital discharge records for the period 1995 through 1997, we examined the results of surgery for all 37,316 children (defined as persons 19 years of age or younger) in Ontario, Canada, who received tympanostomy tubes as their first surgical treatment for otitis media. We determined the time to the first readmission for conditions related to otitis media and the time to the first reinsertion of tympanostomy tubes.

RESULTS

As compared with treatment involving the insertion of tympanostomy tubes alone, adjuvant adenoidectomy was associated with a reduction in the likelihood of reinsertion of tympanostomy tubes (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001) and the likelihood of readmission for conditions related to otitis media (relative risk, 0.5; 95 percent confidence interval, 0.5 to 0.6; P<0.001). The risk of these outcomes was further reduced if an adjuvant adenotonsillectomy was performed. The effect was age-related. Children as young as one year appeared to benefit from adjuvant adenotonsillectomy; the benefit of an adjuvant adenoidectomy was apparent in two-year-olds and was greatest for children three years of age or older.

CONCLUSIONS

Performing an adenoidectomy at the time of the initial insertion of tympanostomy tubes substantially reduces the likelihood of additional hospitalizations and operations related to otitis media among children two years of age or older.

The aetiology of otitis media with effusion: a review

Otitis media with effusion (OME) is the most common cause of deafness in children in the developed world. In this article we aim to present an overview of current research developments on the aetiology of OME and the resulting implications for treatment. In the model we describe, the primary event is inflammation of the middle ear mucosa, usually due to the presence of bacteria. This leads to the release of inflammatory mediators, which cause secretion of a mucin-rich effusion by up-regulating mucin genes. Prolonged stimulation of the inflammatory response and poor mucociliary clearance lead to persistence of the middle ear fluid, giving rise to the clinical presentation of OME. We describe OME in the following sequence: the initial production of the effusion, the composition of the effusion produced, and factors impairing clearance of the effusion.